Can hepatitis C be eradicated in the US?
Posted on April 2, 2015
An important commentary by Brian Edlin and Emily Winkelstein, published in August 2014 in the journal Antiviral Research, outlined key steps that should be taken to accomplish the elimination of hepatitis C in the United States (Edlin BR, Winkelstein ER. Antiviral Res. 2014;110:79-93). This article is freely available on the online AJM Hepatitis C Resource Center (http://hepcresource.amjmed.com). Accomplishing the goal of eradicating hepatitis C is going to be challenging, even with the availability of new all-oral antiviral regimens capable of eliminating HCV infection in as many as 90% or more of patients in as little as 8–12 weeks. Some of the specific challenges detailed in the commentary are as follows:
- Hepatitis C has a long asymptomatic period that may last decades, during which diagnosis will not occur without widespread screening and the virus may be unwittingly transmitted to other persons.
- Most infected people are unaware of their infection
- Populations most affected by the epidemic are burdened by severe stigma and social marginalization, which handicaps the implementation of preventive and therapeutic services for them
- Funding is scant for public health initiatives, or any programs that benefit public well-being, and the need to provide services to marginalized populations in particular has difficulty gaining traction
- Few clinicians have had experience with the newest regimens
- Treatment may be costly and insurance coverage is uncertain
- There is no robust natural immunity and no effective vaccine
Both the CDC and the US Prevention Services Task Force (USPSTF) currently recommend that risk-based HCV screening should be augmented with a one-time screening for people born between 1945 and 1965. This birth-cohort approach targets individuals with the highest prevalence of HCV infection and also removes any behavioral stigma from screening. In line with the recommendations issued by the CDC and the USPSTF, Governor Andrew M. Cuomo of New York State recently signed into law a new Section 2171 of the Public Health Law that requires the offering of a hepatitis C screening test to every individual born between 1945 and 1965 receiving inpatient hospital care or primary care. This new law has been enacted to increase HCV testing in New York State and ensure timely diagnosis and linkage to care. Other States have enacted similar laws. The possible training of community based healthcare providers to screen, diagnose, treat, manage, or appropriately refer patients with HCV, especially with the advent of more efficacious and tolerable therapeutic regimens, may eventually become a key approach to broadening access to effective care.The commentary by Brian Edlin and Emily Winkelstein highlights the action that’s needed to enhance HCV epidemic control efforts. For example, regarding access to care and antiviral treatment, the following steps are needed to assure that all individuals with chronic hepatitis C are offered antiviral therapy:
- Create collaborative action among government, industry, and payers to assure full access to antiviral drugs for all who need them, regardless of insurance coverage or ability to pay
- Educate and train primary care providers and healthcare systems in treating hepatitis C and caring for stigmatized populations including people how inject drugs (PWID)
- Build public health infrastructure where PWID can receive multidisciplinary health services (including prevention and care) without fear of shame or stigma, with characteristics including comprehensive and continuing primary and specialty care, and improved linkage between testing and care
- Develop best-practice guidelines for harm reduction and evidence-based behavioral strategies to provide expert, nonjudgmental care to persons who use illicit drugs
- Create collaboration and cross-training between providers with expertise in hepatitis C treatment and those who provide services to PWID
The commentary authors conclude that eliminating hepatitis C from the United States is possible, but will require a sustained national commitment to reach, test, treat, cure, and prevent every case.